Northern Dimension Partnership in Public Health and Social Well-being Action Plan accompanying the NDPHS Strategy 2020 Adopted by the NDPHS Committee of Senior Representatives on 28 September 2015 Revised by the NDPHS Committee of Senior Representatives on 11 June 2018 Action_Plan_accompanying_NDPHS_Strategy_2020.docx
Table of Contents Acronyms and abbreviations... 1 Executive summary... 3 1. Financial resources... 3 2. Assumptions... 4 3. Horizontal results and activities... 4 Horizontal result 1. Strengthened and more visible role of health and social well-being on the regional agenda in the Northern Dimension area... 4 Horizontal result 2. Strengthened support and involvement of other stakeholders in the NDPHSfacilitated activities... 5 Horizontal result 3. Increased and strengthened policies to improve health and social well-being through regional cooperation... 5 Horizontal result 4. Increased visibility of the NDPHS in the Partner Countries... 6 Horizontal result 5. Ensured coherence and mutual support in addressing regional challenges and opportunities in the area of health and social well-being through a successful leadership of the EU Strategy for the Baltic Sea Region s Health Policy Area... 6 4. Implementation of activities to achieve the objectives in the period of 2015-2020... 7 Objective 1: Reduced impact of HIV, TB and associated infections among key populations at risk, including prisoners, through strengthened prevention and access to treatment... 7 Objective 2: Contained antimicrobial resistance - through inter-sectoral efforts supporting the implementation of regional and global strategies and/or action plans... 13 Objective 3: Reduced impact of non-communicable diseases (NCDs) - through strengthened prevention and addressing lifestyle-related risk factors... 18 Objective 4: Reduced social and health harm from alcohol, tobacco and illicit use of drugs - through strengthening and promotion of multi-sectoral approaches... 22 Objective 5: Adequately addressed health needs related to chronic conditions and demographic changes through strengthened integration and coordination of care and prevention throughout life course at primary care level... 27 Objective 6: Strengthened occupational safety and health and well-being at work - through information and reporting systems, workplace activities and occupational health services... 31 5. Monitoring and Evaluation of the Action Plan... 35 Annex: General information on the NDPHS... 36 Action_Plan_accompanying_NDPHS_Strategy_2020.docx
Acronyms and abbreviations AI Associated infections AMR Antimicrobial resistance BARN The Baltic Antibiotic Resistance Collaborative Network BMI Body Mass Index BSN Baltic Sea Network on Occupational Health and Safety CAESAR Central Asian and Eastern European Surveillance of Antimicrobial Resistance CIHSD Coordinated/Integrated Health Services Delivery CPT Council of Europe s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment CSR NDPHS Committee of Senior Representatives EARS-Net European Antimicrobial Resistance Surveillance Network ECDC European Centre for Disease Prevention and Control EFPC European Forum of Primary Care EMCDDA European Monitoring Centre for Drugs and Drug Addiction ENETOSH European Network Education and Training in Occupational Safety and Health ENWHP European Network for Workplace Health Promotion ESBL Extended Spectrum Beta-Lactamas EUSBSR EU Strategy for the Baltic Sea Region FTA Free Trade Agreement GBD Global Burden of Disease HIPP Health in Prisons Programme/WHO Europe HIV/AIDS Human immunodeficiency virus infection and acquired immune deficiency syndrome HSS Health systems strengthening (action plan) IALI International Association of Labour Inspection ILO International Labour Organization IOM/MHD International Organization for Migration, Migration Health Division LEGOSH ILO Global Database on Occupational Safety and Health Legislation NCD Non-communicable diseases ND Northern Dimension NDPHS Northern Dimension Partnership in Public Health and Social Well-being NGO Non-governmental organisation NIVA Nordic Institute for Advanced Training in Occupational Health NoDARS Northern Dimension Antibiotic Resistance Study OECD The Organisation for Economic Co-operation and Development OSH Occupational safety and health PAC Partnership Annual Conference PHC Primary health care PYLL Potential Years of Life Lost RARHA EU Joint Action on Reducing Alcohol Related Harm Action_Plan_accompanying_NDPHS_Strategy_2020.docx 1
TB Tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS UTI Urinary Tract Infections WHA World Health Assembly WHO World Health Organization WHO Europe WHO Regional Office for Europe Action_Plan_accompanying_NDPHS_Strategy_2020.docx 2
Executive summary The Action Plan accompanies the NDPHS Strategy 2020 and contains detailed information on the planned activities and expected results of the joint work in the period of 2015-2017. The Action Plan presents assumptions for the effective and successful accomplishment of the objectives, highlighting - inter alia - the important role of the funds needed for appointed delegates and experts to initiate and implement thematic activities, and to disseminate the achieved results in the NDPHS Partner Countries. The document informs about horizontal actions aiming to make health and social well-being more visible on the regional agenda, strengthen the relevant policies, attract other stakeholders to the NDPHS actions and increase the recognition of the NDPHS in the Partner Countries. It also presents how the NDPHS will use the leadership role in the EU Strategy for the Baltic Sea Region (Health Policy Area) to improve and promote peoples health through regional cooperation. The Action Plan specifies how the achievement of the six objectives of the NDPHS Strategy 2020 will become conducive to the improvement of human health and social well-being in the Northern Dimension area. It shows the development context for each objective, communicates the need for intergovernmental policy and action and sets a framework (footprint and expected results) for the specific NDPHS activities. These are further described and provided with corresponding deliverables (specific outputs of the joint work to be available by the termination date of the Action Plan). Progress in achieving the expected results for each objective is measured through quantified indicators, with the baseline, target, data source and responsible organisation indicated. A mid-term review of the implementation progress is scheduled for 2018-2019. Introduction The Action Plan accompanies the NDPHS Strategy 2020 and contains detailed information on the planned activities and expected results of the joint work in the period of 2015-2020. The majority of activities listed in the Action Plan will be implemented in all NDPHS Partner Countries. In some indicated cases, they will be executed through a project on a few NDPHS Partner Countries or their selected pilot sites, while the conclusions and recommendations will be disseminated to relevant target groups in the whole Northern Dimension area. 1. Financial resources Effective implementation of the Action Plan requires allocation of funds, necessary: for appointed delegates and experts to actively participate in the activities (working time to prepare for and follow up on the joint work, office expenses, travel costs for meetings etc.); to organise the required meetings, seminars and study visits; for research/mapping work and to produce guidelines, thematic reports and other publications highlighting the results of the NDPHS work; to initiate and implement projects and initiatives; to organise the dissemination of results of the Partnership work in the NDPHS Partner Countries by the respective ministries of health and public health institutes (e.g. national workshops, information campaigns and media events). Action_Plan_accompanying_NDPHS_Strategy_2020.docx 3
2. Assumptions The effective and successful implementation of the Action Plan is dependent upon several other factors: high commitment of the governments of the NDPHS Partner Countries to provide political, financial and practical support to the Partnership work towards the expected results in all objectives of the NDPHS Strategy 2020; clear understanding of a necessity to ensure financial resources for implementation of the planned activities and the risks related to limited and insufficient funding; continuous exchange of information between relevant actors within the NDPHS Partner Countries (including contacts between country senior representatives and NDPHS expert group members) and a good dialogue at a policy-making level to implement the Partnership results; selection of professional, motivated and committed representatives for the future NDPHS Expert Groups by all the NDPHS Partners; high interest and commitment of the nominated Partnership experts to take part in crosscutting activities (exceeding the scope of one single objective of the NDPHS Strategy 2020); clear understanding of expectations, priorities and needs in the expert-level of the Partnership; clear understanding and acceptance of the priority of cooperation goals and expected results among the involved stakeholders; involvement of relevant EU and international organisations in the expert-level work; collaboration with regional an international actors and adherence to regional action frameworks to facilitate synergies and maximise impacts; amplification of links and synergies with approved global and regional policies, strategies and action plans and on-going work relevant for the Northern Dimension area. 3. Horizontal results and activities The listed below results aim to make health and social well-being more visible on the regional agenda, strengthen the relevant policies, attract other stakeholders to the NDPHS actions and increase the recognition of the NDPHS in the Partner Countries. It is the responsibility of all Partner Countries and NDPHS to be active in producing these results. The Secretariat will play an active role in initiating, facilitating and coordinating many of the planned activities. Horizontal result 1. Strengthened and more visible role of health and social well-being on the regional agenda in the Northern Dimension area As stated in the ministerial-level Partnership Annual Conference (PAC 8 in 2011, and PAC 10 in 2013), health and social well-being have to be more widely recognised on the regional cooperation agenda in the Northern Dimension area. While the inclusion of health as a self-standing Priority Area in the EU Strategy for the Baltic Sea Region (EUSBSR) Action Plan in early 2013 was met with satisfaction, further efforts are needed to convince the international, national and local policy- and decision makers of the need to grant health and the social dimension a status, which would be adequate to their role and importance for the region s societies and economies. Furthermore, it should be recognized that most factors that influence health and well-being, such as education, housing, employment, legal and/or residential status, poverty and psychosocial factors, etc. lie outside the health sector. These health determinants are in turn shaped by policies across all sectors, emphasizing a Health in All Policies (HiAP) approach, with the aim of improving the health of Action_Plan_accompanying_NDPHS_Strategy_2020.docx 4
everyone and thereby reduce the absolute effect of determinants on all people as well as targeted interventions that focus on the most affected. Planned activities towards the expected result Cooperate with relevant regional and international actors to include NDPHS-facilitated health and social well-being items on the regional cooperation agenda in the Northern Dimension area. Include provisions regarding health and social well-being and the importance of the HiAP approach, a focus on health inequalities, as well as the Partnership s role, in relevant highlevel and other documents. Disseminate information regarding health and social well-being and HiAP approaches to international, national and local policy- and decision makers and other stakeholders. Horizontal result 2. Strengthened support and involvement of other stakeholders in the NDPHS-facilitated activities During 2010-2013 support and involvement of other stakeholders in the NDPHS activities led to the increased importance and visibility of the NDPHS. This, in turn, put the Partnership in a better position to initiate and influence developments leading to the improvement of health and the quality of life in the Northern Dimension area. Therefore, the Partnership will continue its efforts to create synergies and develop cooperation with regional and international actors active in the health field. Planned activities towards the expected result Work with other relevant stakeholders towards the achievement of the health-related actions and targets as spelled out in the NDPHS Action Plan. Horizontal result 3. Increased and strengthened policies to improve health and social wellbeing through regional cooperation In order to be effective and to guarantee an equitable and sustainable impact, relevant results and recommendations from projects need to be anchored at the policy level. The NDPHS is well positioned to help convey relevant results and recommendations of on-going and completed projects to the policy level: the relevant conclusions and recommendations can be discussed by the NDPHS expert level bodies and be subsequently presented by the NDPHS expert groups for consideration by the NDPHS Committee of Senior Representatives and possibly by the ministerial-level NDPHS Partnership Annual Conference. Planned activities towards the expected result Communicate relevant results of NDPHS projects and/or NDPHS-facilitated projects to the policy level within the NDPHS. Cooperate with relevant stakeholders to communicate the results of NDPHS projects and/or NDPHS-facilitated projects to the policy level in the Northern Dimension area. Approach and encourage stakeholders to communicate, when relevant, the results of their regional projects to the policy level by using the NDPHS. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 5
Horizontal result 4. Increased visibility of the NDPHS in the Partner Countries Whereas other specific visibility-related actions of the Action Plan address the Partnership s outreach activities towards other stakeholders and the general public, this action area aims to further strengthen the commitment and involvement of the NDPHS Partner Countries. This should be done through raising awareness about the Partnership, its achievements, the role of the Partners and possibilities for the Partner Countries to benefit from the cooperation within the NDPHS framework. The consultations between the NDPHS Chair Country and each NDPHS Partner Country would also provide an opportunity to discuss the issues that require support and action from the highest decisionmaking and political level, as well as to discuss how country representatives can enhance the NDPHS visibility at home. Planned activities towards the expected result Arrange a series of meetings and consultations between the NDPHS Chair Country and each NDPHS Partner Country to improve the visibility of the Partnership in the Partner Countries; and advance the implementation of the NDPHS Strategy and Action Plan. Continue the dialogue with the NDPHS Partner Countries and Organisations by highlighting current information about the NDPHS work on home websites. Horizontal result 5. Ensured coherence and mutual support in addressing regional challenges and opportunities in the area of health and social well-being through a successful leadership of the EU Strategy for the Baltic Sea Region s Health Policy Area The role of the NDPHS as the Policy Area Coordinator within the EUSBSR (Policy Area: Health Improving and promoting peoples health, including its social aspects ) allows for a making health more integrated and inclusive in the regional cooperation. In particular, by providing a common frame of reference, the NDPHS has contributed to increased interfacing between relevant stakeholders at various levels and across thematic sectors, and a better division of labour among the existing networks. At the same time, most of the EUSBSR -related activities are coherent with the NDPHS mission as spelled out in the Oslo Declaration and contribute to the strategic aims of the NDPHS, such as: increased visibility and better influence in processes related to allocation of funding for regional cooperation. Through the instrument of the EUSBSR, the Partnership is able to strengthen the message that improving and promoting peoples health, including social aspects, is an important precondition for ensuring sustainable and healthy societies in order to enable economic growth, and for containing future health and social care- related costs. Planned activities towards the expected result Facilitate the development and implementation of actions and flagship projects defined in the Health Policy Area. Monitor and report the implementation progress within the Health Policy Area. Regularly review the relevance of the Health Policy Area as described in the EUSBSR Action Plan. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 6
4. Implementation of activities to achieve the objectives in the period of 2015-2020 Objective 1: Reduced impact of HIV, TB and associated infections among key populations at risk, including prisoners, through strengthened prevention and access to treatment The context The NDPHS Statement on HIV and tuberculosis ( Impact of the HIV/AIDS and tuberculosis on people and economies of the Northern Dimension Countries status quo and the way forward ), approved by the 10 th Partnership Annual Conference in Helsinki on the 22 nd of November 2013, underlines the alarming increase in the spreading of HIV and AIDS, tuberculosis (TB) and associated infections (AI), among the key populations at higher risk. These are vulnerable groups living under socially and economically distressing circumstances, particularly persons using drugs, sex workers, men-havingsex-with-men, migrants, prisoners as well as persons released from prisons. Children and young people are most affected by social circumstances, thus, shall be considered as a group at risk. In addition, these populations at higher risk may suffer from the consequences of harmful use of alcohol, social marginalisation and criminalisation, as well as stigmatisation and discrimination. The complexity and great variation in the epidemiological situation of these groups pose a substantial challenge for the social and health conditions within the Northern Dimension area and, consequently, for the human lives, societies and economies. Prison populations are a vulnerable group in terms of disease emergence and spread. Of special relevance are infectious diseases, particularly the blood-borne, drug use-related infections with hepatitis viruses (here: B and C) and HIV virus. A particular risk, in addition to blood-borne diseases, is associated with airborne transmission of tuberculosis. The particular circumstances of life inside prison increase infection rates, and the revolving door between the prison and civil life allows diseases to spread through the prison walls. Policy and action needs Complex and cross-sectoral character of the HIV, TB and AI situation is neither adequately recognised nor properly addressed within the traditional policy practices. Despite HIV and TB infections spreading beyond state boundaries and competences of individual sectors, the degree of international and multisectoral cooperation in the Northern Dimension area in this thematic field is insufficient. Primary health and psychological and social care measures are rarely combined in an effort to provide integrated prevention, diagnosis, treatment, care and support interventions, with due attention paid to counteracting the negative impact of a harmful use of alcohol and drugs on adherence to HIV, AIDS and TB treatment regimens. The potential of non-governmental organisations (NGOs) that work with the key populations at higher risk for HIV-infection is not utilised to the maximum extent in governmental actions to strengthen the prevention and control of TB and HIV/TB co-infection, and to decrease the harmful consequences of HIV and TB and HIV/TB co-infection. The capacity of the national health care systems to respond to the burden of HIV, TB and AIs is unsatisfactory. The monitoring and provision of epidemiological information of key populations at risk in the Northern Dimension area is assessed as poor, with a diverse availability of data on the current status. The collection of data concerning key populations at risk in the NDPHS Partner Countries is not sufficient, neither is the reporting of such data to UNAIDS. Treatment of HIV, TB and AIs is not always provided in an integrated and patient-focused manner. There are several barriers in the access to treatment which need to be assessed. Recommendations for updating national programmes are needed. EU Joint Action on HIV and co-infection prevention and harm reduction was launched in 2015. One of its components focuses on mapping of barriers to treatment as well as recommendations for updating national programmes. NDPHS shall deliver expertise to the planning and mapping activities, in particular, the need for complex healthcare measures/solutions addressing multiple diseases and co-infections as HIV, TB and Al. According to general ethical principles, imprisonment should not cause any harm or damage to health Action_Plan_accompanying_NDPHS_Strategy_2020.docx 7
of inmates nor aggravate an existing condition. Moreover, the basic principle of prison healthcare says that treatment and care must be equivalent to that which is provided outside prison. This may be problematic if the responsibility for prison healthcare provision in the NDPHS Partner Countries is split between different institutions/ministries. Due to the highly dynamic development in medical science, procedures and practices should be prepared in a coordinated approach that allow prison health care to be raised to a level comparable to that provided to the general population. The access to certain medicines, e.g. antiretroviral medicines for HIV-infection or the more expensive treatment for multidrug- or extensively drug-resistant TB (MDR or XDR TB), should be similar outside and inside prisons. Yet, the high cost and deficiency of these medicines in some NDPHS Partner Countries requires both legislative and budgetary policies. In addition, instruments for HIV control and strategies for prevention of co-infections vary across the Northern Dimension area, calling for improvement in guidelines and routines. Considering these circumstances and descriptions of the core tasks and limits of prison medicine, international cooperation among the NDPHS Partner Countries seems to be a promising strategy to promote the joint development of modern and internationally recognised values of prisoner healthcare and to put the resulting in place. The only viable approach to achieving these developments will be to pursue a continuous and intensive dialogue with the target groups. One of the actions in that respect would be to raise awareness of harm on health from imprisonment as HIPP (Health in Prisons Programme/WHO Europe) and CPT (Council of Europe s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment) standards are not met by all the NDPHS Partner Countries. Another one would consist in encouraging more NDPHS Partner Countries to follow WHO recommendations on how to implement minimum standards for healthy conditions in prisons. The third action would contain preventive harm reduction in intravenous drug abuse. Footprint of the NDPHS work To contribute to improved and better coordinated preventive responses of the national health and social care systems as well as to an equal access to treatment to mitigate the impact of HIV, TB and associated infections in the Northern Dimension area. To contribute to reduced harm on health from imprisonment. Expected results of the NDPHS work Increased awareness and knowledge among relevant decision makers and other actors in the Northern Dimension area about the complexity of the epidemiological situation of HIV, TB and AI and their consequences. Enhanced international and multi-sectoral stakeholder cooperation on HIV,TB and AI-related issues in the Northern Dimension area, with inclusion of NGOs and broader society representatives. Improved effectiveness of HIV, TB and AI prevention actions in the Northern Dimension area. Improved monitoring, disaggregated by groups data collection and reporting of the situation of HIV, TB, AI and evaluation of the effect of interventions among key populations at risk and policy/action response in the Northern Dimension area. Better knowledge on how to improve control of infectious diseases in prisons, especially regarding HIV, TB and HIV-TB co-infection. Raised awareness of harm on health from imprisonment in accordance with HIPP and CPT standards, especially regarding HIV and TB. Improved linkages between medical care in prisons and community public health services. Educational measures for children and young people extensive knowledge on healthy lifestyle, reproductive health, safe sex and relationships' education. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 8
Measuring the progress No. Expected result Indicator Baseline (2015) Target (2020) Data source Responsible organisation 1. Increased awareness and knowledge among relevant decision makers and other actors in the Northern Dimension area about the complexity of the epidemiological situation of HIV, TB, and AI and their consequences No. of countries which have integrated the HIV and TB action recommendations (cf. the NDPHS Statement) into national health policies To be estimated as part of activities 2-3 more HIV and TB programmes Expert group reports Expert-level authorities 2. Enhanced international and multi-sectoral stakeholder cooperation on HIV, TB and AI-related issues in the Northern Dimension area No. of HIV, TB and AI stakeholder cooperation platforms involving NGOs and representatives of other sectors 2 (ECDC and Barents Health meetings) 2-3 more Project reports Expert group reports Expert-level authorities 3. Improved effectiveness of HIV, TB and AI prevention actions in the Northern Dimension area No. of national prevention actions supported 1 (ongoing NDPHS ENPI project) 3-4 Project reports Expert group reports Project leaders Expert-level 4. Improved evaluation of interventions, monitoring, data collection and reporting of the situation of HIV, TB and AI among key populations at risk and policy/action response in the Northern Dimension area No. of monitoring and best practice reports produced and disseminated to decisionmakers and general public 2 (Integrated care for PLHIV and HATBAI epid report) 2 more Expert group reports Expert-level 5. Better knowledge on how to improve control of infectious diseases in prisons, especially regarding HIV, TB and HIV-TB co-infection No. of countries fulfilling diagnostic processes for TB resistance in line with international standards No. of countries monitoring the number of TB (with detected resistances MDR or XDR) plus HIV cases, according to international To be estimated as part of activities At least one more data Relevant national authorities Expert level Action_Plan_accompanying_NDPHS_Strategy_2020.docx 9
standards 6. Raised awareness of harm on health from imprisonment, in accordance with WHO Europe/HIPP and CPT standards, especially regarding HIV and TB No. of countries developing measures to achieve CPT standards No. of countries developing measures to achieve WHO/ HIPP standards To be estimated as part of activities At least one more data Relevant national authorities Expert level 7. Improved linkages between medical care in prisons and community public health services No. of countries establishing a through care situation for HIV & TB patients To be estimated as part of activities At least one more data Relevant national authorities Expert level Planned activities towards the expected results 1. Increased awareness and knowledge among decision makers and other relevant actors in the Northern Dimension area about the complexity of the epidemiological situation of HIV, TB and AI and their consequences Assess the current state of how many countries and to what extent implement the recommendations of the NDPHS Statement Impact of the HIV/AIDS and tuberculosis on people and economies of the Northern Dimension Countries status quo and the way forward. Continue work on identification of policy response areas and optimum measures based on the NDPHS Statement Impact of the HIV/AIDS and tuberculosis on people and economies of the Northern Dimension Countries status quo and the way forward and information from WHO, ECDC and IOM. Develop and disseminate advice for the national ministries and public health institutions of the NDPHS Partner Countries on integrating the HIV and TB recommendations of the NDPHS Statement into the national health policies and programmes. Thematic report containing advice on integrating the HIV, AIDS and TB recommendations of the NDPHS Statement into the national health policies and programmes. 2. Enhanced international and multi-sectoral stakeholder cooperation in the field on HIV, TB and AIrelated issues in the Northern Dimension area Identify and approach relevant NGO and representatives of other sectors as well as stakeholder cooperation platforms dealing with HIV, TB and AI issues in the NDPHS Partner Countries. Stimulate joint meetings between thematic experts and relevant stakeholders, incl. NGOs and broader society representatives, to share experiences and knowledge on the cross-cutting issues of HIV-TB-drugs-alcohol-prison-AMR-PHC etc. Facilitate joint discussion about health systems development and links between the specialised care and the public health care, concerning issues related to HIV, TB & AI. Arrange cross-sectoral study visits for experts on prison health, infectious diseases, primary Action_Plan_accompanying_NDPHS_Strategy_2020.docx 10
health care, alcohol and substance abuse and mental health. Periodical reports (1 per year) summing up outcomes of the joint dialogue, with recommendations to improve policy and action effectiveness in addressing the cross-cutting issues of HIV-TB-drugs-alcohol-prison-AMR-PHC etc. 3. Improved effectiveness of HIV, TB and AI prevention actions in the Northern Dimension area Identify key areas in HIV, TB and AI preventive actions where multi-stakeholder cooperation may bring the most visible added value through EG discussions and analyses, documentation and recommendations, making also use of international information, such as ECDC, WHO, UNAIDS and IOM. Develop a mechanism to make the joint NDPHS experience in the field of HIV and AI better and more widely used by the ministries and organisations in the NDPHS Partner Countries. Provide training, advisory support and expertise in developing initiatives of the NDPHS Partner Countries (e.g. HATBAI seed money project, EU Joint Action on HIV and harm reduction etc.). Provide support to development of educational measures for children and young people extensive knowledge on healthy lifestyle, reproductive health, safe sex and relationships' education. Report on the added value of multi-stakeholder cooperation in HIV, TB and AI preventive actions. Assistance delivered to the ministries and relevant organisations of the NDPHS Partner Countries in the evaluation of project applications and other issues requiring HIV/TB/AI expertise. Technical advice provided to 3 projects and initiatives in the planning and management stage. 4. Improved evaluation of interventions, monitoring, data collection and reporting of the situation of HIV, TB and AI among key populations at risk and policy/action response in the Northern Dimension area Arrange information exchange and benchmarking between the experts of the NDPHS Partner Countries about current epidemiological situation within the HIV, TB and AI, national response policies and good practices solutions. Produce and disseminate (via the NDPHS website, newsletter and/or media events) analytical conclusions and action proposals towards the national authorities responsible for HIV/AIDS, TB and AI. 1-2 reports / 2 years, compiling actual statistical and analytical information on the epidemiological status of HIV, TB and AI risk groups in the NDPHS Partner Countries and containing conclusions and proposals for action based on outcomes of the discussion in the group of cross-sectoral experts. 5. Better knowledge on how to improve control of infectious diseases in prisons, especially regarding HIV, TB and HIV-TB co-infection. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 11
Increase awareness among prison staff and prisoners on how to improve infectious disease control through e.g. study workshops. Develop proposals to implement particular instruments, e.g. diagnostic processes, monitoring mechanisms, for TB control adjusted to specific local conditions. Special focus on MDR and XDR TB and prevention and detection of resistance development, if detected provision of relevant treatment. Develop proposals to implement instruments for HIV control adjusted to specific local conditions. Develop strategies for improvement of other co-infections, e.g. STIs. Concept paper for projects, training programmes and exchange programmes for health care professionals with regard to the implementation of the above mentioned instruments. 6. Raised awareness of harm on health from imprisonment in accordance with HIPP (WHO Europe) and CPT standards, especially regarding HIV and TB Arrange social and psychological counselling for HIV and/or TB positive inmates to improve compliance and therapy adherence. Reports from regional workshops with participation of prison healthcare staff and the corresponding leadership and decision-making level, with conclusions and recommendations to raise the awareness of harm on health from imprisonment. Handbook with fact sheets/recommendations, made available through the NDPHS website and on standards for counselling for HIV and/or TB-positive inmates. 7. Improved linkages between medical care in prisons and community public health services Analyse the current through care situation for HIV & TB patients in the NDPHS Partner Countries. Develop and make a pilot implementation of a through care project in highly problematic prisons to improve the linkage between medical care in prisons and community public health services. Thematic report on the current through-care situation in the NDPHS Partner Countries. Report from the pilot through care project in highly problematic prisons with conclusions and policy/routine recommendations. Target groups authorities responsible for HIV, AIDS, TB and AI (Ministries of Health, Ministries for Social Affairs, Ministries of Justice etc.) Experts working in the field of HIV, TB & AI and harm reduction in national, regional and local administration and in NGOs Medical doctors, nursing staff and other medical personnel in the penitentiary system and in public health institutions NGOs related to the work in penitentiary system Media professionals, general population etc. Key populations at higher risk (see the context information) Action_Plan_accompanying_NDPHS_Strategy_2020.docx 12
Objective 2: Contained antimicrobial resistance - through inter-sectoral efforts supporting the implementation of regional and global strategies and/or action plans The context Since the NDPHS strategy 2020 and its accompanying action plan were adopted in 2015, several significant events and reports have contributed to increased international awareness among politicians, professionals and the general public about the threat of AMR to public health. Most notably: The WHO Global Action Plan (GAP) on containment of antimicrobial resistance was adopted at the World Health Assembly 2015. This plan requests, among other things, all Member States to develop financed national plans to tackle AMR and to implement surveillance systems to increase the knowledge to inform interventions. The United Nations convened a high-level meeting on antimicrobial resistance 2016. Several studies on the potential impact of AMR on public health and global trade were released, for example by the British government (the O Neill report), by OECD and by World Economic Forum. Already before these events, the WHO regional office for Europe and the European Commission launched action plans on antibiotic resistance in 2011, the latter of which was revised in 2017. Several national, regional and global initiatives are now on-going to support GAP. With regard to AMR surveillance, the WHO have developed the GLobal Antimicrobial resistance Surveillance System, GLASS, which is now under early implementation. GLASS applies a harmonized methodology which is aligned with the surveillance systems the NDPHS Partner Countries are already connected to (either CEASAR (Central Asian and Eastern European Surveillance on Antimicrobial Resistance) or EARS-Net (European Antimicrobial Resistance Surveillance Network), but is broader in its scope. Another pillar to record information on antibiotic resistance is the surveillance of antibiotic consumption. While ESAC-Net collect data on antimicrobial use in the EU, key indicators for surveillance of rational use of antibiotics (which are not agreed on) have only been implemented in a few NDPHS Partner Countries. Central for rational use of antibiotics are guidelines. However, little is known how the frameworks for developing and implementing treatment guidelines compare and whether they are built on local/ national resistance data or not. Finally, there is no overarching compilation of the national plans and guidelines on combatting antimicrobial resistance (AMR) in the Northern Dimension area. The impact of these national plans among health care providers and professionals is largely unknown. Moreover, even if the knowledge is increasing about awareness in the general public about the impact AMR has on human and animal health due to the inappropriate use of antibiotics, there is still a lot to learn to be able to tailor interventions. Policy and action needs In preparation of the action plan 2015-2017 it was stressed that the variations in conditions and approaches between the NDPHS Partner Countries require a concerted action among health care providers, professionals and policy makers, on how to combat antimicrobial resistance in the Northern Dimension area. Even if this still is true, it is now expected that the broader scope is covered by national plans aligned with the WHO GAP, and better that the AMR-EG in the NDPHS framework focus on some more specific components. When the AMR-EG action plan 2015-2017 was developed, three work-streams were outlined. Knowledge about the AMR situation in the NDPHS region has suffered from lack of data from representative and comparable AMR surveillance systems. With the launch of GLASS, a harmonized methodology with a broader scope, complementing the existing networks in the region EARS-Net and CAESAR, have become available. The members of the AMR-EG have started a collaboration around early implementation of GLASS. All countries in the AMR-EG have registered for participation in GLASS and some have already managed to upload data to WHO. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 13
Only a few NDPHS Partner Countries have implemented key indicators for rational antibiotic use. The ECDC recently did a survey on surveillance of antibiotic use and indicators among EU member states, which has not been published yet. Information from this survey should be compiled from a NDPHS perspective, and gaps addressed. Such an overview may, together with any related ECDC activities, act as inspiration and priority for NDPHS countries in this area. Increased awareness of prescribers and policymakers on the antibiotic resistance situation in the Northern Dimension area and on specific measures to be taken was identified as a third area for action. Since the development of the action plan 2015, most of NDPHS partner countries have developed national action plans in support of GAP. Still there is no overview of existing treatment guidelines to promote rational use of antibiotics, their national status, and the framework for development and implementation in the NDPHS partner countries. A mapping in this area can lead to lessons to be shared, some harmonization (depending on AMR situation) and sharing of guidelines. The importance of infection prevention and control (IPC) to prevent infections which often need antibiotic treatment and hospital care (and thus further increases the risk for emergence and spread of AMR) was also stressed. However, the AMR-EG has come to the conclusion that the capacity in the expert-group is insufficient to take this area on as well. Instead, it is suggested that NDPHS partners should engage in WHO initiatives such as hand hygiene campaigns and implementation of other developed materials. Furthermore, several aspects of IPC are addressed in the European Joint Action on Antimicrobial Resistance and Associated Infections, EU-JAMRAI, in which several NDPHS partner countries participate. Finally it was noticed in 2015 that there is an insufficient depth of knowledge and awareness in the general public on the impact the AMR has on public health due to the inappropriate use of antibiotics in humans, animals and agriculture, and inefficient prevention and control routines in health care settings. It was suggested that it calls for studies addressing knowledge, attitudes and behaviour in relation to the AMR problems within the NDPHS Partner Countries, but it has become obvious that it is beyond the capacity of the AMR-EG to address these issues as well. Also, most NDPHS countries already engage with national campaigns centred around the European antibiotic Awareness Day and the World Antibiotic Awareness Week. Strategies, responsibilities and approaches to promote appropriate antibiotic use and antibiotic stewardship based on relevant national or local AMR data, including dedicated funding and resources for guideline development and implementation, differ across NDPHS countries and may have a considerable impact on implementation. Footprint of the NDPHS work To contribute to the achievement of more rational use of antibiotics in all sectors (appropriate for relevant diagnose) in the Northern Dimension area based on a better assessment of the antibiotic resistance situation. Expected results of the NDPHS work More representative and comparable systems for surveillance of AMR in the NDPHS Partner Countries. Improved measurement and monitoring of antibiotic use in the NDPHS Partner Countries. Increased awareness of prescribers and policymakers on the antibiotic resistance situation in the Northern Dimension area and on specific measures to be taken, particularly development of treatment guidelines based on national or local AMR data. Measuring the progress Action_Plan_accompanying_NDPHS_Strategy_2020.docx 14
Work - strea m Expected result Indicator Target 2020 Baseline (2015) Status August 2017 Data source Responsib le organizati on 1. More representative and comparable AMR surveillance systems implemented in the NDPHS Partner Countries 2. Improved measurement and monitoring 1.1 Proportion of hospital laboratories reporting to EARS-Net and CEASAR, respectively 1 1.2 No. of countries with data on ESBL carriage rate 1.3 No. of countries with data resistance levels in E. coli causing uncomplicate d UTIs 1.4 No. of NDPHS Partner countries reporting AMR data to GLASS 2 in addition to data reported to EARS-Net or CAESAR 3 1.5 No. of countries reporting implementati on data according to GLASS implementati on questionnaire 2.1 No. of NDPHS 1.1 At least 50% of the laboratories, or hospitals, in the NDPHS Partner Countries 4 1.2 Not defined 1.3 Not defined 1.4 100% 1.5 100% 2.1 80% of the NDPHS Partner 1.1 Existing: FI, LI, LV, NO, SE 1.2 Existing: NO, SE 1.3 Existing: SE 1.4 Not relevant, GLASS was not developed yet. 1.5 Not relevant, GLASS was not developed yet. 2.1 Existing: NO, SE 1.1 Existing: FI, LI, LV, NO, SE 1.2 Existing: DE, FI, NO, LV, PL, RU, SE 1.3 Existing: DE, FI, LV, PL, RU, SE 1.4 Existing: FI, LV,NO, SE 1.5 Existing: DE, FI, LI, LV, NO, PL, SE 2.1 Existing: NO, SE 1.1 CAESA R and EARS- Net 1.2 The NoDAR S project 1.3 The NoDAR S project, 1.4 GLASS 1.5 GLASS 2.1 ESAC- Net Expertlevel 1 Previously the indicator was population coverage, but this is not feasible according to EARS-Net experience. To align with EARS-Net proportion of laboratories, or proportion of hospitals, is proposed instead. 2 GLASS= Global Antimicrobial resistance Surveillance System 3 New indicator 2018-2020 4 New target adapted to above Action_Plan_accompanying_NDPHS_Strategy_2020.docx 15
of antibiotic use in the Northern Dimension area countries with national key indicators for surveillance of antibiotic consumption/ use 2.2 No. of NDPHS countries with national targets for antibiotic consumption/ use Countries 2.2 50% of the NDPHS Partner Countries 2.2 Existing: SE, NO 2.2 Existing: SE, NO authoriti es 2.2 authoriti es Expertlevel 3. Increased awareness of prescribers and policymakers on the antibiotic resistance situation in the Northern Dimension area and on measures to be taken to promote rational use of antibiotics in human sector 5 3.1 No. of NDPHS countries with an action plan on AMR according to GAP 6 3.2 No. of NDPHS countries with framework for developing and implementing national treatment guidelines for common infections 3.1 100% of the NDPHS Partner Countries 3.2 50% 3.3 50% 3.1 Existing: DE, NO, PL 7, RU, SE 3.2 Existing: FI, PL, SE 3.3 FI, SE 3.1 Existing: DE, FI, NO, PL 7, RU, SE 3.2 Existing: FI, PL, SE 3.3 FI, SE 3.1 authoriti es 3.2 authoriti es3.3 authoriti es Expertlevel 3.3 Surveillance data is used to inform national treatment guidelines Achievements and deliverables 2015-2017 and planned activities 2018-2020 towards the expected results. 1. More representative and comparable AMR surveillance systems developed for implementation in the NDPHS Partner Countries Establishing sentinel AMR surveillance sites to investigate the levels of specified antimicrobial resistance at the selected locations within the Northern Dimension area. Implementation of harmonized AMR surveillance methodology in the region through 5 Slightly rephrased/ specified for 2018-2020 6 Reformulated due to the introduction of the Global Action Plan on antimicrobial resistance, GAP 7 Poland s plan so far only covers human sector Action_Plan_accompanying_NDPHS_Strategy_2020.docx 16
participation in EARS-Net or CAESAR (coordinated by the ECDC and WHO EURO, respectively) and participation in GLASS. Workshop with participants from NDPHS Partner Countries to exchange experience and harmonise/improve data coverage for the AMR surveillance systems. Expand implementation of harmonized AMR surveillance. Achievements and deliverables: Some of the previously noted gaps in AMR surveillance in the NDPHS Partner Countries, namely lack of comparable and harmonized data from a representative population, have been addressed in the NoDARS project, where resistance in bacteria collected in the community (asymptomatic stool carriage in healthy individuals and bacterial isolates causing acute cystitis in women) in the partner countries have been assessed. Recommendations for harmonisation and improvement of AMR surveillance systems in the NDPHS Partner Countries have been made available in WHO documents developed for early implementation of GLASS. All NDPHS countries have registered for early implementation of GLASS, and a few have already delivered data to WHO. Workshops on implementation and methodology for surveillance according to GLASS have been organized at the international level and in each NDPHS member state separately in the NorthernGLASS project. The output from the project will be a report 2018 with conclusions summing up discussions between experts and policy makers from the NDPHS Partner Countries regarding lessons learned from early implementation of GLASS. AMR surveillance will be expanded through gradual extension of GLASS to include more pathogens and specimen types and to increase national coverage by increasing number of surveillance sites delivering data. By future extension of GLASS participation within partner countries, increasingly better and more representative and comparable routine data will be available to inform interventions and treatment guidelines. 2. Improved measurement and monitoring of antibiotic use in the Northern Dimension area. Achievements and deliverables: There have been no specific activities within the NDPHS framework 2015-2017 in this area. Inventory of key indicators for surveillance of, and targets for, rational antibiotic consumption/use in the NDPHS Partner Countries. Suggest appropriate key indicators to accurately reflect rational antibiotic use and consumption in the NDPHS Partner Countries. 3. Increased awareness of prescribers and policymakers on the antibiotic resistance situation in the Northern Dimension area and on specific measures to be taken Map existing Plans aligned with GAP in the NDPHS partner countries particular in regard to AMR surveillance and antibiotic use. Map frameworks and regulations for development and implementation of treatment guidelines for common infections in the NDPHS region Review national treatment guidelines for common infections and assessment of connection to local/national AMR surveillance data. Specifically (if possible) assess whether they are based on AMR surveillance data that are overestimating antibiotic resistance. Action_Plan_accompanying_NDPHS_Strategy_2020.docx 17